Acute care under simultaneous RAC, UPIC, 340B, and Joint Commission pressure.
The engagement
A CDI and status-documentation posture that holds under DRG validation; a written read on extrapolated exposure across claim types; RAC and UPIC response packets built to the contractor’s criteria; and recovered dollars through appeal.
Week 1 — intake: claim-type exposure, audit posture, and CDI standing. Weeks 2–4 — documentation, status, and DRG review against the coverage rules. Ongoing — pre-bill review, query-practice coaching, and audit response as demands arrive.
Regulatory context
Hospital review pressure is structural, not episodic. The FY2026 IPPS final rule (August 2025) reset rates and quality-program requirements, while the FY2025 CERT cycle kept inpatient E/M and DRG-sensitive documentation at the top of the improper-payment table — subsequent inpatient visits (99233) alone account for over $490 million. Status determinations remain governed by the two-midnight rule, which makes medical-necessity documentation the deciding evidence on admission-status review.
Underneath the payment rules, program-integrity contractors run concurrently: RACs on DRG validation and status, UPICs where analytics flag an outlier, the SMRC on CMS-assigned national reviews, and CERT sampling across it all. Because UPIC findings extrapolate, the documentation pattern — not the single claim — is the real exposure.
From revenue cycle through audit defense — each shaped to your operation.
The cross-cutting capabilities we bring to acute care, framed for hospital scale:
Each service shaped to the specific pressure observed.
Three reasons hospitals choose us for the engagements that matter:
Methodology before scale. Our case-file approach was developed working both sides of healthcare audit — inside government program integrity and on the defense side. We know what contractor findings look like before they leave the contractor's desk.
Credentialed where it counts. PI license, Certified Fraud Examiner, direct UPIC, MAC, RAC, and SUR experience. The credentials hold up at ALJ and in commercial litigation requiring expert testimony.
We tell you the truth. If a finding is going to stick, we say so. If self-disclosure is the right move, we say so. The work has to hold up at hearing — we can't oversell what's defensible.
What drives most hospital improper payments?
Documentation that doesn’t support the billed level: subsequent inpatient visits and DRG-sensitive coding lead the FY2025 CERT findings. The pattern, repeated across claims, is the exposure.
Can a DRG downgrade or status denial be appealed?
Yes. We rebuild the clinical record against the coverage standard and challenge the methodology where findings were extrapolated; properly built appeals frequently reduce demands.
How does CDI connect to audit defense?
They’re the same record. A query practice built to the coverage rules produces documentation that defends itself — before the payer asks.
Are you a law firm?
No. We’re the evidence bench — expert consultants and licensed investigators who build the record and the methodology challenge your counsel argues from. We can serve as testifying experts. Nothing here is legal advice.
Tell us what you are up against. Scoping memo in week one, before any meaningful commitment.